| 37 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2017-10-12 |
221 |
E |
0 |
1 |
Z18S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents were assessed, care planned, and physician's orders were obtained for the use of geriatric chairs for 2 of 10 sampled residents (Resident #1, #6) and 1 unsampled resident (Resident #11). Findings include: Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was observed repeatedly from the hours of 7:30 AM to 5:00 PM, on 10/09/17 through 10/12/17, sitting in a geriatric chair (Geri-Chair a large padded chair with wheeled bases designed to assist seniors with limited mobility) in the dining room. Resident #1's clinical record lacked documented evidence of a physician's order for a Geri-Chair, an assessment for the use, and a care plan for the Geri-Chair. On 10/12/17 at 10:12 AM, a Registered Nurse (RN) verbalized Resident #1's Geri-Chair was not a restraint because the resident needed the device. The RN confirmed Resident #1's clinical record lacked documented evidence of the need for a Geri-Chair. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was observed 10/9/17 through 10/12/17 from the hours of 7:30 AM to 5:00 PM, sitting in a Geri-Chair in the dining room. Resident #6's clinical record lacked documented evidence of a physician order, assessment and care plan for the use of the Geri-Chair. Resident #11 Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #11 was observed 10/9/17 through 10/12/17 from the hours of 7:30 AM to 5:00 PM, sitting in a Geri-Chair in the dining room. Resident #11's clinical record lacked documented evidence of a physician order, assessment and care plan for the use of the Geri-Chair. On 10/11/17 at 3:00 PM, a Unit Manager and a Certified Nursing Aide (CNA) confirmed Resident #1, #6 and #11 had not been assessed, a care plan implemented, or a physician's order obtained for the use of the Geri-Chair. The CNA verbalized a Geri-Chair was not a physical restraint because there was no tray in use to lock the chair to prevent the resident from standing. The CNA confirmed a resident could not get out of a Geri-Chair when reclined position. On 10/12/17 at 10:15 AM, the Director of Nursing (DON) confirmed the facility lacked documented evidence the Geri-Chair was not being used as a physical restraint for Resident #1, #6 and #11. The DON confirmed the residents' clinical records lacked documentation for the need for the Geri-Chair to include an order, assessment, or care plan. The facility policy titled Restraints, revised 04/15/16, documented physical restraints included facility practices meeting the definition of restraint such as placing a resident in a chair that prevented the resident from rising. All residents were to have an assessment performed to determine the safety and protective needs of the resident prior to the application of restraints or medical protective device and at least every 90 days. The facility was to have a medical provider order the restraint and the order should have been renewed monthly. Medical Conditions warranting the use of restraints should have been documented in the resident's medical record, ongoing assessments, and care plans. |
2020-09-01 |